Newborn · Pain
NIPS — Newborn Infant Pain Scale
Pain assessment for newborns (0-1 month): 6 behavioural items, 0-7 score. Babies DO feel pain. Breastfeeding + sucrose + skin-to-skin proven to reduce procedure pain. Lawrence 1993; Cochrane evidence.
Last reviewed 2 June 2026
NIPS — neonatal infant pain scale
Pre-term and term newborn pain assessment
Score all 6 items to see total.
Educational tool only — not medical advice. NIPS validated for term and pre-term newborns. Other neonatal scales: PIPP (premature), CRIES (postoperative), N-PASS (extended care). Non-pharmacological measures (skin-to-skin, breastfeeding, sucrose 24 %, non-nutritive sucking) are first-line for procedural pain.
What does this mean?
The NIPS (Lawrence 1993) was developed specifically for neonates — older pain scales rely on self-report or movement patterns that don’t apply to newborns. Score ≥ 4 = significant pain warranting intervention. Non-pharmacological measures come first and have remarkable effectiveness: (1) sucrose 24 % drops orally 2 min before procedure (Stevens 2016 Cochrane: halves cry duration for heel-pricks); (2) breastfeeding during the procedure (Shah 2012 Cochrane: equivalent or better than sucrose); (3) skin-to-skin / kangaroo care reduces pain response (Johnston 2017 Cochrane); (4) non-nutritive sucking (pacifier); (5) swaddling, gentle voice, dim light. For surgical pain, paracetamol IV/PR + opioids titrated to NIPS, with non-pharm bundled alongside. Pre-term babies use the PIPP score (Premature Infant Pain Profile) which adjusts for GA. Repeated unmanaged pain in NICU is linked to altered later pain processing — this is not a benign issue.
What is NIPS?
Neonatal Infant Pain Scale — pain assessment for newborns (term + preterm). 6 behavioural items, total 0-7. Lawrence 1993.
- 0-2: no/mild pain — comfort measures.
- 3-4: moderate — comfort + simple analgesia.
- 5-7: severe — pharmacological intervention.
Babies do feel pain
Full pain pathways developed by 24 weeks gestation. Preterm even more pain-sensitive. Repeated procedures without analgesia can sensitise pain pathways long-term.
Procedures that can cause pain
- Heel prick blood tests.
- Vaccines.
- ROP (retinopathy of prematurity) screening.
- Cannulation.
- Chest drain.
- Intubation.
- Lumbar puncture.
- Surgery.
Pain management strategies
- Breastfeeding during procedure — gold standard.
- Sucrose drops (24% glucose) — place on tongue 2 min before.
- Non-nutritive sucking — pacifier.
- Skin-to-skin (kangaroo care).
- Facilitated tucking (flexed position).
- Swaddling.
- Gentle touch + voice.
- Paracetamol oral / rectal for moderate.
- Morphine / fentanyl for severe.
- Topical anaesthetic (Emla, Ametop) for IV insertion (>32 wk; not heel pricks).
Breastfeeding for procedures
Strongly evidence-based. Multiple studies + Cochrane: breastfeeding (or breast milk via syringe) significantly reduces pain response — comparable to sucrose, possibly better.
Mechanism: taste + smell + skin contact + sucking + comfort combined.
Sucrose drops
24% solution. 2 min before procedure. Sweet-taste triggers endogenous opioid release. Cochrane-supported. Safe; minimal side effects.
Paracetamol dosing in newborns
- Term neonates: 7.5-10 mg/kg every 6-8 hours; max 30 mg/kg/day.
- Preterm: lower doses, less frequent.
- Avoid <2 kg or <34 weeks unless specialist.
- Routes: oral, rectal, IV in NICU.
Preterm pain sensitivity
Pathways not fully formed; lower thresholds; less mature inhibitory pathways. Repeated procedures cumulative effect.
Extra care: minimise procedures; cluster care; kangaroo care; sucrose; parent presence; quiet environment.
Parent role
- Breastfeeding during procedures.
- Skin-to-skin.
- Comforting voice + touch.
- Advocating for pain management plan.
- Familiarity with baby’s signs.
Different scenarios
Scenario 1: Heel prick for newborn blood spot screen
Breastfeed during procedure OR sucrose drops + non-nutritive sucking. Reduces pain significantly.
Scenario 2: NICU preterm baby, multiple IV cannulation attempts
Emla cream + sucrose + facilitated tucking. Cluster care planning. Parent presence + voice.
Scenario 3: Post-circumcision (where applicable)
Local anaesthetic blocks + sucrose + breastfeeding. Paracetamol post.
Scenario 4: Vaccine pain at 8 weeks
Breastfeeding during. Sucrose if not feeding. Distraction. Paracetamol if MenB given.
Scenario 5: Post-surgical NICU baby
IV morphine titrated to NIPS. Wean as healing. Non-pharm measures alongside. Parent participation.
Care guidance — newborn pain
- Babies DO feel pain.
- Breastfeed during procedures when possible.
- Sucrose if not feeding.
- Skin-to-skin powerful analgesic.
- Paracetamol weight-based, safely.
- Preterm: extra vigilance.
- Parent presence helps.
- Advocate for pain management plan.
- Don’t accept “they won’t remember” — brain pathways set up.
Sources
- Lawrence J, et al. The development of a tool to assess neonatal pain. Neonatal Netw 1993.
- Cochrane Review. Sucrose for procedural pain in neonates.
- Cochrane Review. Breastfeeding for procedural pain in neonates.
- BAPM. Pain management in the newborn.
Frequently asked questions
What is NIPS?
NEONATAL INFANT PAIN SCALE — pain assessment for newborns (term + preterm), 0-1 month typically. 6 BEHAVIOURAL ITEMS scored 0-1 (or 0-2 for cry): facial expression, cry, breathing, arms, legs, state of arousal. TOTAL 0-7. Lawrence et al. 1993. VALIDATED + widely used in NICUs, postnatal wards. SIMPLE; quick (60 seconds). ALTERNATIVE for newborns who can't self-report. INFORMS pain management before/after procedures.
Why does my newborn need pain assessment?
BABIES DO FEEL PAIN — historic view that newborns 'don't feel pain' is WRONG. RESEARCH (since 1980s): full pain pathways developed by 24 wk gestation; preterm even more pain-sensitive. EXPOSURE to multiple procedures (heel pricks, IVs, intubation) without analgesia/comfort can SENSITISE pain pathways long-term — increased pain responses later in life. ASSESSMENT identifies pain; ENABLES intervention; PROTECTS development.
What painful procedures might my baby experience?
ROUTINE: heel prick blood tests (newborn screening, glucose checks); vaccines; ROP (retinopathy of prematurity) screening; nappy changes can be painful for preterm; injections. NICU: cannulation; chest drain; intubation; LP (lumbar puncture); surgery. ALL HAVE pain management approaches available.
How is pain managed in newborns?
(1) BREASTFEEDING during procedure — reduces pain response significantly (gold standard for heel pricks etc.); (2) SUCROSE drops (24% glucose solution) — for infants who can't breastfeed; place few drops on tongue 2 min before procedure; lasts ~5 min; (3) NON-NUTRITIVE SUCKING — pacifier; (4) SKIN-TO-SKIN (kangaroo care) — proven analgesic effect; (5) FACILITATED TUCKING (holding flexed position); (6) SWADDLING; (7) GENTLE TOUCH, voice; (8) PHARMACOLOGICAL when needed — paracetamol oral/rectal for moderate; morphine/fentanyl for severe; (9) TOPICAL anaesthetic (Emla, Ametop) for IV insertion (>32 wk, not heel pricks - ineffective).
How does NIPS score work?
OBSERVE baby for 1 minute. Score each item: FACIAL: 0 relaxed, 1 grimace. CRY: 0 no cry, 1 whimper, 2 vigorous cry. BREATHING: 0 relaxed, 1 change. ARMS: 0 relaxed, 1 flexed/extended. LEGS: 0 relaxed, 1 flexed/extended. STATE: 0 sleeping/awake, 1 fussy. TOTAL 0-7. 0-2: NO/MILD pain — comfort measures. 3-4: MODERATE — comfort + simple analgesia. 5-7: SEVERE — pharmacological intervention needed. REPEAT post-intervention.
What's sucrose for pain?
24% SUCROSE solution drops on tongue 2 minutes before procedure. EVIDENCE: significantly reduces pain response in newborns (multiple RCTs, Cochrane review). PROBABLY works via SWEET-TASTE activated endogenous opioid release. SAFE; minimal side effects. PRESCRIBED in many UK NHS hospitals. SOMETIMES used for procedures up to 12 months. NOT a substitute for full anaesthesia for surgery — for minor procedures (heel prick, vaccines, IV cannulation, NG tube).
Can breastfeeding be used during procedures?
YES — strongly evidence-based for procedure-related pain. EVIDENCE: multiple studies + Cochrane review confirm breastfeeding (or breast milk via syringe) significantly reduces pain response — comparable to sucrose, possibly better. MECHANISM: combination of taste, taste, smell, skin contact, sucking, comfort. PRACTICAL: latch baby on, then perform procedure. SUITABLE for: heel pricks, vaccines, NG insertion, cannulation. EVEN A LITTLE breast milk on tongue helps if baby not feeding.
Should babies have paracetamol?
YES — when indicated. ROUTES: oral, rectal, IV in NICU. DOSES: NEONATES (term, 0-28 days): 7.5-10 mg/kg every 6-8 hours; max 30 mg/kg/day. PRETERM: lower (5-10 mg/kg, less frequent). OVER-DOSING risk if not weight-based. INDICATIONS: post-procedure pain, post-operative, vaccine fever discomfort. AVOID: <2 KG; <34 WEEKS (paracetamol pharmacokinetics different). ALWAYS check with neonatal team.
What about preterm pain sensitivity?
PRETERM babies more sensitive — pathways not fully formed; lower thresholds; less mature inhibitory pathways. REPEATED procedures cumulative; may affect long-term pain perception, attention, behaviour. EXTRA care: minimise procedures; CLUSTER care (multiple things at once); KANGAROO care; sucrose; PARENT presence; HANDLING with care; QUIET environment between procedures. NICU 'PAIN PREVENTION' approach emphasised.
Will pain affect baby long-term?
EVIDENCE: poorly-managed neonatal pain associated with: (1) ALTERED pain processing later — increased sensitivity; (2) BEHAVIOURAL changes; (3) STRESS RESPONSE alterations; (4) SLEEP, feeding disruption in NICU; (5) POSSIBLE attention/cognitive effects. WELL-MANAGED pain: minimal long-term effects; brain plasticity allows recovery. CHRONIC PAIN in childhood: rare but possible. PARENTAL bonding + skin-to-skin protective. ADVOCATE for pain management — ask team about plan.
Can I be present for painful procedures?
OFTEN YES — encouraged. CAN HELP with: breastfeeding during procedure; skin-to-skin; sucrose administration; comforting; speaking. ASK NICU/postnatal team. SOMETIMES separate room/parent corridor for hygiene reasons. YOUR PRESENCE helps baby's pain response. PHOTOGRAPHY allowed in many units. PARTNERS encouraged to participate.
What about chronic pain in babies?
RARE but exists. CAUSES: complex surgical conditions; chronic illness; certain neurological conditions. ASSESSMENT difficult. SPECIALIST: paediatric pain team. APPROACH: multimodal — pharmacological + non-pharmacological + parent involvement. NEONATAL PAIN CLINICS in specialist hospitals. EXTREMELY individualised plans.
What about pain medication risks?
PARACETAMOL: weight-based dosing safe. OPIOIDS (morphine, fentanyl): used carefully; respiratory depression risk monitored; tolerance/withdrawal possible after prolonged use (NICU). LOCAL ANAESTHETIC (Emla, Ametop): generally safe; small absorption; not effective for heel pricks (need superficial site for finger-prick). NSAIDs (ibuprofen): avoided in neonates < 6 months. ALL meds: balance benefit vs risk; comfort measures alongside.
What's the role of parents in pain management?
CRUCIAL: (1) BREASTFEEDING during procedures; (2) SKIN-TO-SKIN; (3) COMFORTING — voice, gentle touch, swaddling; (4) ADVOCATING for pain management; (5) PRESENCE reduces stress; (6) FAMILIARITY with baby's signs. PROFESSIONALS RECOGNISE parents as integral to pain care. ASK for pain management plan; speak up if you think baby uncomfortable.
How does this relate to other calculators on BumpBites?
Companion: /calculators/flacc-pain for older infants (2+ months); /calculators/apgar-score; /calculators/breastfeeding-latch (breastfeeding for procedures); /calculators/newborn-bilirubin (heel prick context); /calculators/vaccine-scheduler (vaccination pain); /calculators/pediatric-dose for medication safety.